Community Education Intervention Project:

The Importance of Healthy Fueling for Collegiate Athletes

University of Notre Dame Sports Nutrition

March 23, 2017
Dakkota Deem
ARAMARK Dietetic Internship

Overview

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 Notre Dame Sports Nutrition (NDSN) is an entity within the University

of Notre Dames Sports Performance Team, located in South Bend, Indiana,

that provides nutrition services 20 athletic teams at the university. The

Sports Performance Team (SPT) consists of sports medicine, athletic training,

rehabilitation services, strength and conditioning, equipment, and sports

nutrition. Because fueling for student-athletes can impact both performance

and health outcomes, it is important to understand the needs, beliefs, and

attitudes of each individual.

NDSNs specific mission is to exemplify the science and value of

nutrition programming to maximize the bodys ability to reach optimal

performance levels, on and off the field. Finding fun and convenient ways to

incorporate performance enhancing food into the lives of athletes is critical

to the mission of NDSN.

A survey was conducted at Training Table to assess the needs and

behaviors of the student-athlete population at Notre Dame. A cooking

demonstration/educational session was then performed at South Dining Hall

to address specific nutrition-related problems within the student-athlete

population. The outcome of the intervention was that 90% would be more

likely to eat breakfast within 1 hour of waking, 100% identified 1 benefit of

eating breakfast, 1 sign and 1 risk of energy deficiency, and 80% would be

more likely to prepare meals/snacks in the dormitories. Limitations include

the number of survey participants and limited marketing for the event. All

materials used during the demo are available to view in Appendix Section.

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Nutrition Assessment (Domains)

Client History (CH)

Personal History (1), Patient/Client/Family Medical/Health History (2), Social

History (3.1)

The University of Notre Dame is a private, co-ed institution that

enrolled over 8,000 undergraduates and had a total enrollment of 12,292, in

2014.1 About 52% of the student population is male, while the other 48% is

female.2 The University is both selective and diverse. In 2015, the 90% of

admitted students came from the top 10% of their high school class.1

Caucasians make up the majority of enrollees, followed by Hispanic/Latinos,

Asians, Non-Resident Aliens, Two or More Races, African Americans, American

Indians, and Pacific Islanders with 70.5%, 10.4%, 5.7%, 4.8%, 4.1%, 3.7%,

0.2%, and 0.1% respectively.2 Notre Dame has 26 teams that compete in the

ACC and at the NCAA Division 1-A level. The athletic programs consist of

mens and womens basketball, cross country, fencing, golf, lacrosse, soccer,

swimming and diving, tennis, track and field, mens football and ice hockey,

and womens volleyball and rowing. These programs have produced the

second most Academic All-Americans among division 1-A universities.4

Notre Dame is a Catholic University, originally founded by a priest of

the Congregation of Holy Cross, in 1842. The university was one of the first

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to study Catholicism in primary and secondary education, and is now

considered one of the leading undergraduate teaching and research

institutions in the United States. The religious presence on campus is

evident, with 55 men and women, of various religious backgrounds, actively

providing a pastoral presence on campus.2 80% of undergraduate students

enrolled at Notre Dame are Catholic, with the other 20% having different

religious affiliations.2 Catholics generally adopt a holistic view on overall

health and believe that health status is ultimately determined by Christ.3 The

Catholic religion practices both fasting and restriction of meat throughout

various days of Lent, as an act of spiritual self discipline.3 As a way of

commemorating Christs crucifixion, Catholics do not eat meat on Fridays,

with the exception of fish. On Ash Wednesday (February 14th), a partial fast

is observed as well as on Good Friday (April 14th).

Chronic diseases are not common in college athletics, including the

population at Notre Dame. Recent studies suggest, however, that athletes

requiring high-calorie consumption with high body indexes, such as offensive

lineman, may be at risk for insulin resistance and other metabolic disorders.5

More common, are acute issues that arise such as eating disorders,

dehydration, vitamin and mineral deficiency, the Female Athlete Triad, and

relative energy deficiency (RED-S). Female Athlete Triad is a well known issue

among sports medical personnel, that focuses on menstrual function, bone

mineral density, and energy availability. Only recently has the Female Athlete

Triad been expanded by the International Olympic Committee to include

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(RED-S). RED-S is caused by inadequate energy intake relative to energy

expenditure or caloric demands of the athlete.6 Hallmark characteristics of

RED-S are impaired physiological function that affects metabolic rate,

menstrual function, risk for fractures/bone health, immunity, protein

synthesis, and cardiovascular health caused by either chronic or acute

energy deficiency.6 A recent systematic review reported the prevalence of

any single component of the Female Athlete Triad, as 16-20% among

athletes.7 No statistics currently exist on the prevalence of either disorder at

Notre Dame, however preventing REDs and components of the female

athlete triad is a top concern according to NDSN personnel.

Food/Nutrition Related History (FH)

Diet History (1.1), Eating Environment (1.1.3), Food and Beverage Intake

(1.3), Medication and Herbal Supplement Use (2), Mealtime Behavior (4.4),

Factors Affecting Food and Food/Nutrition Related Supplies (5)

Physical fitness and all around well being is a primary concern of Notre

Dame Athletics. The Irish Sports Performance Team is the moving force

behind overall health and well being of the student athletes. Registered

Dietitians, strength and conditioning coaches, athletic trainers, and team

physicians all collaborate to develop new programs, enhance existing

training protocols and use research to assist our student-athletes and

coaches in improving their overall health, nutrition and athletic

performance.4 Four full-time Registered Dietitians work with the chef and

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local restaurants to provide nearly 3,000 meals to athletes, daily. Training

Table, a meal offered at no cost to the athletes, is executed by the Student

Welfare and Development Committee, the chef, and the RD. The meal is

provided 5pm - 8pm each night of the week as a way to promote the

consumption of healthy, well-balanced meals for overall health and

performance. Notre Dame Football is provided 2 training table meals each

day (breakfast and dinner) in addition to lunch, 2 days of the week. If there

are athletic, performance, health, weight, or other safety concerns, the

sports performance team meets with the student, and action plan a solution.

Most athletes report attend training table 5-7 times per week according to

survey results. Most frequently, athletes reported consuming 3-4 meals per

day, and snacking in between meals. Greater than 50% of athletes reported

no to eating breakfast within 1 hour of waking due to time constraints,

greater than 50% did not feel that they had the skills or resources to prepare

meals/snacks in the dorm due to time constraints, and reported fueling for

exercise within 1 hour of physical activity. A majority of surveys also indicate

that the variety of food is good or excellent at training table and are

willing to try new types of food.

About 80% of undergraduate students live on campus at Notre Dame.

Refrigerators and microwaves must be provided by the student, if one is

desired in the dorm room. Residence Life restricts the use of hot plates and

induction cooktops within the dormitories, however a microwave and kitchen

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are provided in the common area. Most athletes indicate having access to a

fridge according to survey results.

Herbal supplements are not commonly used by the athletes, as the

National College Athletic Association has strict guidelines that categorize

supplements as permissible, impermissible, and banned. If an athlete is

interested in taking a specific supplement, the athlete may bring the

supplement to the RD and compliance committee for further review.

Impermissible supplements may only be provided to the athlete with a

prescription by an ordering physician.

Biochemical Data, Medical Tests and Procedures (BD),

Anthropometric Measurements (AD), and Comparative Standards

(CS)

Body composition/growth/weight history (AD-1.1), Vitamin and Mineral

Profile (BD-1.13), Energy Needs (CS-1)

Body composition and vitamin/mineral lab tests are performed three

times per year by the RD and medical staff, as a means of evaluating

training efficacy, lifestyle habits, micronutrient needs, relative energy intake,

and energy needs. Vitamins and minerals of specific interest are vitamin D,

calcium, B12 and Iron. Once need is established, a dosing regimen is

established based on the needs of the athlete The energy needs of elite

athletes are much higher than the needs of the average person. It is

generally accepted that the athlete in the high activity category, needs

about 45 calories/kg. of lean body mass to prevent relative energy deficiency

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and allow for adequate recovery. In order to fuel appropriately for sport, a

well balanced performance plate (geared toward the goals of the athlete)

should be consumed 2-3 hours prior to exercise, or modified meal should be

consumed 1-2 hours prior to exercise. Body mass measurements are taken

bi-weekly during the main athletic season and evaluated by the SPT. The SPT

then reviews and addresses any concerns and the RD may provide

permissible nutritional supplements and counseling to the athletes as

needed.

Nutrition Diagnosis

PES Statement

Food and nutrition-related knowledge deficit (NB-1.1) related to lack of prior

exposure quick and healthy meal recipes in college dorms and nutrition-

related information about healthy fueling for exercise as evidenced by

>50% of respondents not eating breakfast due to time restraints, >50% of

respondents fueling inappropriately for exercise, unintended weight loss

patterns during the season per RD, and need for nutrition education/cooking

demonstration.

Intervention

Diet education and a cooking demonstration was provided to the

student athletes to address the nutrition diagnosis. According to the

responses on the Training Table Questionnaire, a majority of students feel

as though they do not have time to eat breakfast, and/or are not fueling

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appropriately for exercise. The below interventions are geared toward the

prevention of the RED-S and associated conditions within ND athletics, and

aim to develop the skills and knowledge of student-athletes to

prepare/compose healthful meals and fuel appropriately for exercise.

Nutrition Education (E-1.5): Recommended modifications

Nutrition Education (E-1.1): Pre- exercise fueling and healthy meal

composition

Nutrition Education (E-2.2): Skill development

Healthy People 2020

Healthy People 2020 (HP2020) is a program developed by the Office of

Disease Prevention and Health Promotion (ODPHP). The ODPHP initiative sets

forth SMART (specific, measureable, achievable, realistic, time-bound)

objectives and science based goals that encourage collaborations across

communities and sectors, empower individuals toward making informed

health decisions, and measure the impact of prevention activities.8 Goals and

objectives are evaluated every 10 years.

One topic that Healthy People 2020 focuses on is Educational and

Community-Based Programs (ECBP).

Goal: Increase the proportion of college and university students who receive

information from their institution on each of the priority health risk behavior

areas (all priority areas; unintentional injury; violence; suicide; tobacco use

and addiction; alcohol or other drug use; unintended pregnancy; HIV/AIDS

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and STD infection; unhealthy dietary patterns; and inadequate physical

activity).

Objective (ECBP 7.1): Increase the proportion of college and university

students who receive information from their institution on each of the priority

health risk behavior (PHRB) areas

In 2009, HP2020 found that 9.6% of college and university students

were provided education on each of the behaviors mentioned in the goal.8

HP2020 realized the importance of educating students on each of the PHRBs

and set a goal to increase the number of institutions providing PHRB

education to 10.6 percent by 2020.8 This goal presented by HP202 meets the

criteria for a SMART goal; The topic, population, and target are specific, an

increase in the number of institutions providing PHRB education to 10.6

percent is measurable using the National College Health Assessment (NCHA)

and American College Health Association (ACHA) surveys, the target is

achievable and realistic compared to the data from 2009, and contains a

time-framed goal of 1 percent increase in 10 years, 2010-2020. ECBPs play

a large role in disease and injury prevention, improving health and quality of

life, and are great ways to reach members of the community in a non-
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traditional way. Providing nutrition education as a means of disease and

injury prevention is an emerging trend in the field of dietetics, and is

addressed by the objective, and following intervention.

Lesson Plan

Notre Dame Sports Nutrition Training Table

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 A cooking demonstration/ educational session will be presented to the

student-athletes at the University of Notre Dame during a Training Table

meal. Training Table is provided to athletes on every day of the week, with

cooking demonstrations/education provided each month. The focus of this

demonstration will be on fueling appropriately for exercise and preparing

quick, healthy meals in the dorm (See Lesson Plan in Appendix A). The

Dietetic Intern will collaborate with the chef to establish and obtain a date

and time for the demonstration, ingredients, and other materials necessary

for the execution of the project. During the demonstration participants are

invited to prepare their own recipe to take with them, and asked to complete

a brief survey.

Marketing

A majority of the athletes at ND attend training table 5-7 days per

week and all athletes reported attending at least 1-2 days per week,

therefore no extensive marketing/promotion was needed for the education

session. Table-toppers describing the event were placed in South Dining Hall

one week prior to the session (Available in Appendix C). The four Ps of

marketing technique, or the marketing mix, was used to develop the

marketing materials: Product, Price, Place, and Promotion. The product was

chia seed pudding and it met the customer demand of a quick and easy

snacking option for the athletes. Price did not need to be included in the

marketing, as training table is provided free-of-charge to the athletes. The

place, or location of the event, was training table in South Dining Hall. As

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previously stated, a majority of the athletes at Notre Dame attend training

table, and this was the best location to get the best participation. Lastly the

promotion was meant to appeal to student-athletes, in particular. Student

athletes have hectic schedules and dont want to be worried about preparing

a meal. The promotion was meant to appeal to those looking for a healthy

fueling strategy that can be made in the dorm, and practically prepares itself

overnight. (available in Appendix C) and provided free of charge. In the

future, sending out an e-mail to the athletes or handing out flyers can help

increase attendance. The total cost for marketing materials was $2.

Resources

The resources required for the execution of the of the education and

cooking demonstration include recipe ingredients, mixing bowls, measuring

cups, plastic cups and lids, spoons, and educational handouts. All of the

educational resources were provided by NDSN and the ingredients, utensils,

and plastic-ware were on- hand and provided by South Dining Hall. The

estimated total cost of resources is $90. No budget was Established for the

event.

Monitoring and Evaluation

A post-test method was utilized to evaluate the efficacy of the

education session and cooking demonstration. Overall, participants did seem

to enjoy the demo and the provided recipe, although some did not enjoy the

texture of the chia seeds. (See Appendix B for Evaluation Documents).

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 Total participation in the event was about 160 athletes with varying

sport affiliations. The participants played an active role in the session by

preparing their own recipes and asking questions throughout the

presentation. After the presentation was complete, participants were asked

to fill out the brief post-test and leave them at the demonstration table upon

completion. Upon review of the post-test, 90% of participants would be more

likely to eat breakfast within 1 hour of waking, 100% could identify the

appropriate times to fuel for exercise, 100% could name 1 benefit of eating

breakfast, 100% could identify 1 sign and risk of RED-S, and 80% would be

more likely to prepare meals/snacks in the dormitories. There were

limitations to the evaluation method such as participants discussing the

questions and answers, prior to submission of the post-test.

Recommendations for future demonstrations include elaborating more

on plate composition and other recovery strategies. Although healthy fueling

strategies were discussed throughout the education session, general

healthful eating and post-exercise recovery could be discussed in more

depth. Another recommendation would be to discuss easy dorm-friendly

breakfast recipes as to avoid any texture aversions that were encountered

during this demonstration.

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Appendix A: Lesson Plan

Lesson Title: How Are You Fueling?

Target Audience: University of Notre Dame Student-Athletes
General Objective or Class Goal:
Date and Duration: March 23, 2017; 3-hour demonstration
Example of Goal: Participants will increase their knowledge about fueling for exercise, Relative
Energy Deficiency, and preparing healthy meals/snacks in the dorms.

Specific Procedure Learning Evaluation

Objectives (State how each specific objective Activity Method
(Use SMART will be met)
criteria)

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 Introduction
1.Introduce self to participants and Verbal N/A
explain the purpose of the Discussion
demonstration, and a general overview
of topics to be discussed.

2.State feelings on the importance of

being able to make quick and healthy
meals in the dorm.

3.Discuss the importance of how fueling

inappropriately can hinder athletic
performance.

Body of Lesson
1. Participants will Review of Macronutrients: Verbal Verbal Q&A
be able to describe 1. Carbohydrates, Protein, Fat Explanation
one benefit of a. Role of Macronutrients and Written
eating breakfast and sources. Materials Post test
with 100% b. Plant sources of protein
accuracy, by the for Fridays during Lent.
end of this session. 2. Overview of fruits and
vegetables.
3. Breakfast-Why is it so
Important?
a. Two Words: Break-Fast,
>8hrs, a majority of
glycogen stores are used
up.
b. Cortisol- Muscle
breakdown and fat
storage
4. Breakfast Can:
a. Increase strength and
energy in workouts
b. Decrease muscle
breakdown
c. Help with focus in class
d. Help avoid relative
energy deficiency.
(discussed later)

2. By the end of the 1. Chia Seed Pudding (provide Verbal Visual

session, samples and distribute materials Explanation inspection.
participants will be for preparation and recipes.
able to prepare the 2. Walk participants through the Demonstratio Verbal Q&A

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recipe, provided at recipe. n
the demonstration. 3. Describe nutritional benefits of
the recipe and stress quickness Written
and ease. Materials
4. Add fruit for extra Carbohydrates
and nutrients.
2. Participants will 1. How long should you be eating Verbal Verbal Q&A
be able to identify before exercise? Explanation
appropriate fueling a. Food must be digested
times for exercise, to be used for energy Post test
with 100 % b. 1+ hours
accuracy, by the 2. 1-2 hours before
end of this session. a. lower fiber, fat with
protein and CHO
b. Gatorade Energy Bar,
UCANN
3. 2+ hours- Well balanced meal
using the plate (1/2 color
protein and starch)-Draw
4. Intra workout >45minutes
a. Fast digesting CHO
(applesauce, banana,
energy chews, animal
crackers, gummies)
5. Eat within 30 min of workout for
recovery
a. Replenish Fluids
3. Participants will 1. What is Relative Energy Verbal Verbal Q&A
be able to identify 1 Deficiency/Female Athlete Explanation
symptom and 1 risk Triad?
associated with a. Calories in<calories out Post test
Relative Energy b. Athletes need more
Deficiency With calories than average
100% accuracy, by people, due to work out
the end of this demands and body
session. composition.
2. Risks: Impaired growth and
development, impaired
metabolism, decreased
immunity and bone health,
hormonal imbalance,
reproductive consequences.
3. Signs/Symptoms: Lack of
normal growth, extreme
lethargy/declining athletic
performance, menstrual
dysfunction, recurrent injuries,
mood changes.

Conclusion

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 1.Eating breakfast every day to get Verbal Questions
Closing Remarks the most out of your workout and Conclusion
keep performing at your best, every
day.
2. Pinterest has a ton of easy dorm
recipes that can save a lot of time in
the morning, which will allow you to
sleep in longer
3. if you are having concerns or are
experiencing symptoms, talk with the
RD or your coach.

Thank the participants for coming

and remind them to drop off post-
tests on the way out.
Lesson Plan References:

1. Dunford M, Doyle A. Nutrition for Sport and Exercise, 2nd edition.

Wadsworth Publishing: 2008.
2. Marcason, Wendy. Female Athlete Triad or Relative Energy Deficiency in
Sports (RED-S): Is There a Difference? Journal of the Academy of
Nutrition and Dietetics. Volume 116, Issue 4, 744
Materials:

1. Demo Table
2. Demo Foods:
a. Sweetened vanilla or chocolate Almond Breeze, chia seeds,
vanilla extract, maple syrup, honey, cinnamon, cardamom,
cinnamon, peanut butter, jelly, almond extract, assorted nuts,
cocoa powder, fresh cut fruit.
3. Kitchen Equipment:
a. Three Large Bowls, plastic spoons and cups, measuring spoons,
measuring cups, condiment cups (for ingredients), tasting
spoons, 2 oz. portion cups, 2 oz. spoodles.

Appendix B: Evaluation Documents-Training Table

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Table Questionnaire

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Food Demo Post-Test:

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Appendix C: Additional Materials

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Table-Top Flyer

Recipe Card:

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Benefits of Chia Handout:

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Evaluate Your Plate Handout:

References:

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1. U.S. News & World Report L.P. Best Colleges

Rankings.https://www.usnews.com/best-colleges/notre-dame-1840.

Published 2017. Accessed April 4, 2017.

2. Undergraduate Admissions: ENR Statistics. University of Notre Dame

Admissions. 2017. Available at:

http://admissions.nd.edu/apply/admission-statistics/. Accessed April 4,

2017.
3. John Paul II. (2000). Prayer of the holy father for the catholic physician.

Retrieved April 1, 2017, from

www.healthpastoral.org/wordofpope/med_pray
4. About: University of Notre Dame Sports Performance.

Performancendedu. 2017. Available at:

https://performance.nd.edu/about/. Accessed April 4, 2017.

5. Borchers, J. R., Clem, K. L., Habash, D. L., Nagaraja, H. N., Stokley, L.

M., & Best, T. M. (2009). Metabolic Syndrome and Insulin Resistance in

Division 1 Collegiate Football Players. Medicine and Science in Sports

and Exercise, 41(12), 10.1249/MSS.0b013e3181abdfec.

http://doi.org/10.1249/MSS.0b013e3181abdfec
6. Mountjoy M., Sundgot-Borgen J., Burke L., et. al. The IOC consensus

statement: beyond the Female Athlete TriadRelative Energy

Deficiency in Sport (RED-S). Br J Sports Med. 2014;48:491-497.

7. Stickler L, Hoogenboom BJ, Smith L. THE FEMALE ATHLETE TRIADWHAT

EVERY PHYSICAL THERAPIST SHOULD KNOW. International Journal of

Sports Physical Therapy. 2015;10(4):563-571.

8. About Healthy People. Healthy People 2020. Available at:

https://www.healthypeople.gov/2020/About-Healthy-People. Accessed

March 30, 2017.

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